Eyeworld

EW FEATURE 116 byline goes here plus fade AT A GLANCE • text goes here. • text goes here. • text goes here. who develop some rebound inflam- mation and need a drop supple- ment. In my own personal practice, it is closer to the 2% mark, but some others have reported it to be as high as 10%. The difference is that the patient only has to be on one drop postoperatively that he takes a couple of times a day, and with- in a week or so the inflammation is gone. It is very easy to treat and does not involves weeks of different drops given at different intervals, so it is still better for the patient, even those that break through," he said. Postoperative vision varies, mostly because TriMoxi and Tri- MoxiVanc are opaque and can be unsatisfying for patients and for surgeons who value immediate post- operative visual results as a measure of surgical success. "We are putting a milky substance into the vitreous, so vision on the day of surgery varies tremendously. I've seen same-day postoperative patients who have very poor vision and can only count fingers to others who have 20/20. It boils down to whether the TriMoxi is in front of the macula or not. If it is out of the way, they are going to see some floaters, and if it is in the way, they may have poor vision for a few hours. I tell my patients here to expect that this is the tradeoff for getting out of drops. Expect poor vision on the day of surgery, and ex- pect some floaters on the top part of vision typically for 1 to 3 days, after which it will absorb and vision will clear," Dr. Galloway explained. Overall, a one-shot surgical prophylaxis regimen gives patients and physicians significant peace of mind. In addition, TriMoxi saves the patient between $300 and $500 on postoperative drops. "There is a sub- stantial savings to the patients using TriMoxi. It actually costs the surgery center about $20 for Trimoxi and $25 for TriMoxiVanc. We also save a significant amount of time counsel- ing patients about drops, in phone calls from pharmacies, for substitu- tions, and so on. On the service side, we save valuable time and energy," he said. Intracameral According to Dr. Mah, injecting postoperative meds is a smart, proac- tive move toward taking the respon- sibility out of the patient's hands and into his own. "I think there are several reasons that surgeons are reacting negatively toward drops to- day, and trying to take that responsi- bility from the patient. One big rea- son is compliance. You have no idea what the patient is doing, if he has picked up the medication(s), picked up the prescribed medication(s), if he is applying it correctly, or has the help he needs to take the meds. These unknowns strongly influence surgical outcomes, and the surgeon should have more control here," Dr. Mah said. In addition, "efficacy is another reason to consider new drug delivery methods like the Imprimis or Dextenza [Ocular Therapeutix, Bedford, Massachusetts] or other types of 'dropless' cataract surgery such as compounded dexametha- sone-moxifloxacin [Ocular Science, Manhattan Beach, California] which is what I have actually been using. I apply meds intracamerally. There is voluminous medical literature supporting the intracameral method of prophylaxis including prospective clinical trials. It brings into question the topical method of prophylaxis, where the efficacy of these medica- tions is out of our hands. Why not use something that can be more efficacious and takes outcomes issues away from the patient?" he said. Dr. Mah opts for an intracam- eral approach to apply postopera- tive prophylactic meds, choosing to avoid the transzonular and pars plana approaches. Although TriMoxi and TriMoxiVanc offer the all-in-one approach, there are a few reasons he prefers not to use it. "Firstly, I am in favor of avoiding intraocular vancomycin until the incidence and association of vancomycin with hemorrhagic occlusive retinal vasculitis (HORV) is elucidated and debunked. As for triamcinolone, it is only usable in the vitreous, which I do not feel is necessary. It has a long half-life, which can be a big prob- lem in steroid responders. Also, as a suspension, triamcinolone leaves vi- sion blurry for at least a day or two, or longer, even if everything else goes perfectly. I prefer to assess my patient's vision right after surgery, and patients appreciate immediate improved vision," he said. Dr. Mah also noted that not all patients can afford to have poor vision for days after surgery. Dr. Mah explained that know- ing the effective lens position immediately following surgery was a key factor in managing premi- um patients (i.e., those primari- ly electing to have surgery with largely non-reimbursable products). He thinks that manipulating the Going continued from page 115

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